Carbophobia: The Dieting
Public’s Obsession with Carbohydrates and the U.S.
Government’s Response

By Jeremy Berry

J.D., Harvard Law School, 2003

May 16, 2003

Carbophobia: The Dieting
Public’s Obsession with Carbohydrates and the U.S.
Government’s Response[1]

Abstract:

This paper examines the recent low-carbohydrate
diet craze, and analyzes the reaction of the United States
government to new scientific evidence potentially indicating that
the government’s current food recommendations may actually be
contributing to the obesity epidemic in America. After a brief
introduction, the paper examines the history of food science,
focusing on the government’s efforts to develop the food
recommendations now in the Food Guide Pyramid, as well as recent
studies indicating that other diets may be more effective for
weight loss and cardiovascular health. The paper then discusses the
generally-accepted science of what constitutes the various
macronutrients, as well as how carbohydrates are processed by the
human body. Next, four of the most popular diets in America today
are analyzed, including their recommendations and the science,
sometimes controversial, behind these diet recommendations. The
four diets analyzed are a low-fat diet, a low-carbohydrate diet
such as the Atkins Diet, a mixed diet such as the Zone Diet, and
the SugarBusters Diet and other low-glycemic index diets. The
science background concludes by noting where the science seems to
be converging, despite vast differences of opinion amongst the
various diet advocates. Next, the U.S. government’s
recommendations and response to these studies are analyzed,
particularly in three contexts: the recommendation that Americans
consumer more “whole grains;” the problem the
government has had in defining what constitutes a “complex
carbohydrate;” and the choices the government faces in
defining a “carbohydrate,” including why the government
may have made the wrong choice. The paper concludes with several
proposals the government should take to update its food
recommendations and increase the health of the American public.
Generally speaking, the recommendations are for the USDA to revise
its Food Guide Pyramid to reflect current knowledge about
carbohydrates, and for the FDA to allow food manufacturers to list
the glycemic load on food labels. If the government makes these
changes, the health of the American public should improve, or, at a
minimum, American consumers will find it easier to improve their
health.

I. Introduction

In the United States alone, over 97.1 million
adults (54.9% of the adult population) are overweight, defined as
having a body mass index greater than 25. 22.3% of the adult
population, or 39.8 million, are obese, defined as having a body
mass index greater than 30. From 1960 to 1994, obesity increased in
the U.S. by over 50%, from from 13.4 to 22.3 percent of the adult
population, with most of this increase coming in the last decade.
This fattening of America costs $99.2 billion each year, with $51.6
billion as direct costs of obesity and overweight. This is
equivalent to 5.7% of the total US health expenditure each year.
Americans may be fatter than ever, but they’re spending more
and more on weight loss products and services- $33 billion annually
throughout the 1990’s.[2]

One avenue Americans are increasingly turning
towards is limiting their intake of carbohydrates, as advocated by
the popular and controversial Dr. Atkins. The health agencies of
the United States government have been some of Dr. Atkins’
staunchest opponents, continuing to advocate a high-carbohydrate
low-fat diet despite recent evidence indicating the pitfalls of
such an approach. The obsession with carbohydrate intake, and the
government agencies’ response to it, is the focus of this
paper.

II. History of Food Science

A. Governmental Developments, Including the
Development of the Dietary Guidelines and Food Guide Pyramid

Mothers and grandmothers have undoubtedly been
telling their offspring for centuries what to eat, but using
science to determine nutritional needs is a relatively new
phenomenon. In 1894 W.O. Atwater, the first director of the Office
of Experiment Stations in the U.S. Department of Agriculture,
published tables of food composition and dietary standards for
Americans. The tables provided information on protein, fat,
carbohydrate, ash, and “fuel” (calorie) content for
some of the most common foods. Atwater was the first scientist to
link dietary intake to health, and though he did not publish a food
guide as such, he did recognize the importance of scientifically
determining what foods would lead to a proper intake of essential
nutrients, stating that “... for the great majority of people
in good health, the ordinary food materials- meats, fish, eggs,
milk, butter, cheese, sugar, flour, meal and potatoes and other
vegetables- make a fitting diet, and the main question is to use
them in the kinds and proportions fitted to the actual needs of the
body.”[3]

Building upon Atwater’s work, Caroline L.
Hunt, a nutrition specialist in USDA’s Bureau of Home
Economics, developed the first food guide in 1916. The guide
categorized foods into five food groups: milk and meat; cereals;
vegetables and fruits; fats and fat foods; and sugars and sugary
foods. Although they did have recommended daily servings for each
of the five food groups, Hunt’s publications were generally
more similar to buying guides, listing foods to buy each week, as
well as recipes and menus.[4]

The weekly buying guides would continue to dominate
until the 1940’s, when daily dietary guides first began to
appear. In 1941 the Food and Nutrition Board of the National
Academy of Sciences released the first Recommended Dietary
Allowances (RDA’s) at the National Nutrition Conference for
Defense. RDA’s were given for calories, protein, and eight
vitamins and minerals. The Bureau of Home Economics of the USDA
issued a daily food guide to assist with obtaining these essential
nutrients, entitled “Eat the Right Food to Help Keep You
Fit.”

The daily guides were updated until 1958, when the
USDA issued its Food for Fitness—A Daily Food Guide,
introducing the idea of the “Basic Four,” or the four
food groups- milk and milk products; meat, fish, poultry, eggs dry
beans and nuts; fruits and vegetables; and grain products. The
“Basic Four” set minimum consumption for these four
food groups, but gave little guidance on how many calories to
consume, what else to consume, or on fat and sugars. The Basic Four
would remain the focal point of nutrition education until 1979,
when the USDA would add a fifth food group- fats, sweets, and
alcohol.[5]

Federal involvement in American nutrition reached a
turning point in February 1977 when the U.S. Senate Select
Committee on Nutrition and Human Needs issued its Dietary Goals
for the United States . The Committee set goals for the intake
of protein, carbohydrate, fat, fatty acids, cholesterol, sugars,
and sodium. Because USDA studies showed that the diets necessary to
reach those goals were too different from usual food patterns of
Americans to be useful, the Goals were not adopted by the USDA as
the basis for food plans and guides.

Although the Goals were not embraced by the USDA
for its food guides, the adoption of the Goals by Congress sent a
clear signal that the American public needed a better, more
authoritative food guide than what was being used for educational
purposes until then. Therefore, in 1980, the Department of Health
and Human Services, in conjunction with the United States
Department of Agriculture, issued Nutrition and Your Health:
Dietary Guidelines for Americans , first edition. The
Guidelines were based on the most current science at the time,
focusing on the nutritional needs of healthy Americans. For the
second, 1985 edition, USDA and HHS appointed a Dietary Guidelines
Advisory Committee of prominent experts in nutrition and health to
review the scientific and medical knowledge current at the time and
recommend to the Secretaries revisions to the Guidelines. The
Committee has been created each of the times since then that
revisions have been made, every five years.

In 1990 Congress passed legislation officially
requiring the USDA and HHS to publish jointly every 5 years a
report entitled The Dietary Guidelines for Americans, thereby
requiring what the agencies had previously done
voluntarily.[6] The report must contain nutritional and dietary
information and guidelines for the general public, and be based on
the preponderance of scientific and medical knowledge current at
the time of publication. The report will be promoted by each
Federal agency in carrying out any Federal food, nutrition, or
health program.

In the early 1980’s nutritionists began
expressing displeasure with the “Basic Four” food
guide, and desired something more specific as a food guide. In
response, the USDA created a new daily food guide. This new food
guide was to be consistent with the new Dietary Guidelines for
Americans , and also help the public to achieve the RDA’s
as published by the National Academy of Sciences. The food guide,
created to be a reference for total daily nutrition, was to be easy
to use and simple to understand, so that everybody would use it.
The result, first published in 1992, was the USDA Food Guide
Pyramid.

The Food Guide Pyramid, last updated in 1996,
emphasized grains such as bread, cereal, rice and pasta, with these
making up the bottom layer of the pyramid at 6 to 11 servings per
day.[8] The next layer up is divided between the vegetable
group, at 3 to 5 servings per day, and the fruit group, at 2 to 4
servings per day. The layer after that is the milk, yogurt, and
cheese group (2 to 3 servings per day), as well as the meat,
poultry, fish, dry beans, eggs, and nuts group (2 to 3 servings per
day). The top of the pyramid consists of fats, oils, and sweets,
all to be used sparingly.[9]

B. Private Developments in the Modern History of
Food Science

In 1972, Dr. Robert C. Atkins published his own
dietary guidelines with Dr. Atkins’ Diet Revolution .
Although the diet guide and updated versions have sold over 16
million copies, it did not garner positive scientific treatment
until recently, nor did it originally attract the phenomenal
publicity it now does.[10] From the start Atkins was denounced by the
mainstream scientists, especially by the Journal of the American
Medical Association, possibly due to his flamboyant claims about
his diet. Atkins did not help his acceptance by the mainstream
nutritionists and dieticians by boasting that his diet was
“the high-calorie was to stay thin forever” and by
advocating bacon, eggs, cheese, and other sources of saturated
fats.[11] In the 1970’s, Dr. Atkins was arguing that
people could lose weight while eating foods laden with saturated
fat, such as lobster with butter sauce or bacon cheeseburgers.
Unfortunately for Dr. Atkins, the late 1970’s also marked the
beginning of the low-fat trend by nutritionists, and studies
linking saturated fat to heart disease were being released, making
the Atkins diet’s claims sound preposterous and
dangerous.

The 1980’s marked the height of the low-fat
movement, and once the USDA put fat at the top of the Food Guide
Pyramid and even noted on the cover of the brochure to limit fat
intake to no more than 30% of calories, commercial forces took
over, ensuring that the reduced-fat recommendations of the
government would not go unnoticed. The food industry began
producing thousands of products with less fat than their leading
competitors, and soon “low-fat” versions of
America’s favorite foods were available everywhere. Usually
the fats were replaced with sugars, of equally dubious health
claims, but so long as the food industry could label the products
“low-fat,” the American public would buy them, usually
with the belief that it was better for them than the non-reduced
fat versions. Since these products had to compete with regular,
non-reduced fat versions of the same foods, advertising and
labeling was greatly increased, trumpeting the low-fat message of
greater health benefits. Soon the majority of the American public
was consuming less fat, in an effort to be healthier, as
recommended to them by the USDA and HHS.[12]

By the 1990’s, Americans were eating less fat
but still not getting any thinner. Dr. Atkins published his updated
book in 1992, and this time the American public, if not the
nutritionists and scientists, began embracing the low-carbohydrate
diet. The mass paperback of Dr. Atkins’ book sold over 15
million copies in the 1990’s, making it one of the top
sellers of the decade.[13] The Atkins Diet had arrived.

The Atkins Diet supposedly works by restricting
carbohydrates so low that people actually go into a state of
ketosis, in which insulin levels fall so low that the muscles and
tissues of the body burn body fat for energy, as during starvation.
Mainstream food scientists said that ketosis was dangerous, and
that it can be excessively hard on the kidneys.[14]

During the 1990’s, other diets also became
popular with the American public. In 1995 Dr. Barry Sears published
his diet book, A Week in the Zone, which, combined with other
titles by Dr. Sears, has now sold over 4 million copies.[15] The Zone Diet, as Dr. Sears has called his
recommendations, is based on the body’s hormonal responses to
the foods it is fed. The diet strives to have insulin levels within
a certain zone (hence the name), neither too high nor too low. To
accomplish this, Dr. Sears recommends eating a low-fat protein
source with each meal, as well as lots of fruits and vegetables.
The meal is to be finished off by adding a touch of fat, usually
monounsaturated fats in olive oil, nuts, or some salad dressings.
Most importantly, the Zone Diet does not recommend consuming large
amounts of grains and other complex carbohydrates, as they tend to
release large amounts of insulin, causing insulin spikes which are
followed by crashes. Because Dr. Sears advocates replacing some of
the lost complex carbohydrates with protein and fat, his diet is
neither a low-fat diet such as that prescribed by the USDA, nor a
low-carbohydrate diet such as that prescribed by Dr.
Atkins.[16] Dr. Sears states that the most important
principles of his diet are balance and moderation- balancing the
foods you eat with each meal, and limiting portion sizes of any one
food group.[17]

In 1998 H. Leighton Steward, Morrison Bethea, M.D.,
Sam Andrews, M.D., and Luis Balart, M.D., introduced a new diet
book into the mainstream, Sugar Busters, which, combined with other
titles, has sold 2.5 million copies.[18] Like Dr. Sears and the Zone Diet, Sugar Busters
attempts to restrict the release of insulin into the body by
avoiding refined carbohydrates and sugars. Sugar Busters brought
the notion of a glycemic index into the mainstream; the glycemic
index is a measure of how much insulin a certain food product will
cause the body to release. According to Sugar Busters, foods with
higher glycemic indices cause more insulin, which in turn forces
those calories into fat rather than being used for energy, and
which also makes the person hungry again sooner.

The Sugar Busters diet recommends more protein than
the USDA but less than Atkins or Sears, and on the Sugar Busters
diet one still consumes bread, pasta, and cereal, as long as
they’re whole wheat and sugarless.[19] Sugar Busters is more cautious of fat than the
Zone Diet, although it does allow for unsaturated fats used in
moderation.[20] Sugar Buster is easier to follow than the Zone
Diet, also, in that it categorizes foods into
“acceptable” and “to avoid.”[21]

It is important to note that all of the diets
described above (Atkins, Zone, and Sugar Busters) disagree with the
USDA Food Guide Pyramid and blame it for the obesity epidemic
facing America. All of them disagree with the base of the Food
Guide Pyramid, that of bread, cereal, rice and pasta. Atkins and
the Zone argue that this is too many carbohydrates, and Sugar
Busters insists on whole wheat carbohydrate sources, as well as
more fruits and vegetables and less refined carbohydrates.

July 7, 2002 was one of the most gratifying days of
Dr. Atkins’ life.[22] On that day, the New York Times Magazine ran a
cover story suggesting that Dr. Atkins’ diet might be both
effective at weight loss and good for you. The story, “What
If It’s All Been A Big Fat Lie,” is inconclusive but
suggestive that the mainstream food scientists have been wrong all
these years, and that they may wake up to someday find that Dr.
Atkins has been right all along. The story gave instant credibility
to Dr. Atkins, who rode the wave of publicity to the bank with his
company, Atkins Nutritionals.[23]

The story also brought to the forefront of the
public mind the scientific studies on the various diets that have
been done and are being done. Because scientific studies have been
inconclusive at best, with some proving a low-fat diet is best,
others proving a low-carbohydrate diet is best, and still others
proving that a balance is necessary, the public seems to be unsure
of where to turn for nutrition advice. On the one hand, they saw
the government sticking with its Dietary Guidelines for Americans,
and the corresponding Food Guide Pyramid with bread, cereal, rice
and pasta still at the base. On the other hand, each of these other
popular diets had millions of adherents, as well as scientific
evidence to back up their claims. The American public has been
told, at various times, that fat is bad for your heart and will
make you gain weight, that protein is bad for your kidneys and may
increase the risk of heat disease, and that carbohydrates make you
fat and increase the risk of heart disease.

A. The Science of Macronutrients

The science behind these diets, and the American
government’s response to the various scientific studies, will
be discussed shortly. But first, it is necessary to acquire an
understanding of the basic nutritional concepts on which each of
the studies builds. Thus, before we begin examining the
controversial studies proposed by the proponents of each of the
diets, let us begin by examining the basic, non-controversial
science behind nutrition and food science.

First, the body needs energy, in the form of
calories, to survive. Energy can come from fat stores or even the
body’s digestion of its own muscle tissue, but the most
common source of energy is food. All calories humans ingest can be
traced to one of four sources, or macronutrients: protein,
carbohydrates, fats, and alcohol. Protein and carbohydrates have
roughly 4 calories per gram, fats have roughly 9 calories per gram,
and alcohol has a little more than 7 calories per gram. For the
most part, we will ignore alcohol as a source of calories, as it is
devoid of most of the vitamins and minerals the body needs to
survive and has its own deleterious health consequences.

Proteins are composed of amino acids linked end to
end, with the number and sequence of the amino acids giving each
protein its unique characteristics. There are 20 different amino
acids, and of these, the body can manufacture all but nine. These
nine are therefore called the essential amino acids, as the body
must ingest them and cannot make them from other amino acids. The
remaining eleven amino acids are nonessential amino acids, meaning
that the body could use a surplus of one to alleviate a deficiency
of another nonessential amino acid.[24] Animal products such as meat, eggs, and milk
provide the richest sources of both essential and nonessential
amino acids, meaning that they contain complete proteins. Some
plant products contain significant amounts of amino acids, but no
one plant product contains all of the essential amino acids, making
plant proteins incomplete proteins.

Carbohydrates are long chains of sugar molecules
(also known as saccharides) bound together. Carbohydrates can be
classified based on how many sugars are linked together.
Monosaccharides are single sugars, such as fructose, galactose and
glucose. Disaccharides are two sugars linked together, including
sucrose (table sugar) and lactose (milk sugar). Polysaccharides,
frequently described as being complex carbohydrates, are three or
more sugars linked together, and include starch, glycogen, and
fiber.[25]

The human digestive system breaks starches down
into disaccharides, and disaccharides down into monosaccharides.
These monosaccharides are released through the small intestine into
the blood stream, where the liver breaks down fructose and
galactose into glucose, the body’s primary energy source. If
more glucose is available than the body currently needs for energy
purposes, it is turned into glycogen, a stored form of
carbohydrate. Glycogen is stored in the muscles and liver, or can
be converted into fat and stored in the body’s fat deposits.
Unlike all other carbohydrates, the body is incapable of breaking
down fiber into monosaccharides, and thus fiber passes intact
through the digestive system. Therefore, fiber is not a significant
source of energy for the human body.

Fat is a group of chemical compounds that contain
fatty acids. There are four types of fatty acids: saturated,
monounsaturated, polyunsaturated, and trans-fatty acids. All fatty
acids are composed mostly of carbon and hydrogen atoms. A saturated
fatty acid has the maximum possible number of hydrogen atoms
attached to each carbon atom. A monounsaturated fatty acid is
missing one pair of hydrogen atoms in the fatty acid molecule. A
polyunsaturated fatty acid is missing more than one pair of
hydrogen atoms. Trans fatty acids have had some of the missing
hydrogen repairs replaced through partial hydrogenation.[26]

Saturated fatty acids are most commonly found in
meat products, especially red meat, butter, and cheese. Unsaturated
fatty acids tend to be found from plant sources, especially olive
oil, avocados, and nuts. However, salmon and other fatty fish often
contain significant amounts of omega-3 polyunsaturated fatty acids,
which have been shown in some studies to have beneficial effects on
cholesterol and triglyceride levels, possibly leading to decreased
chances of heart attacks.[27]

Next, let’s examine how the body processes
carbohydrates a little more in-depth, so that we can better
understand the debates between the various parties and the
scientific studies behind them. As previously stated, all
carbohydrates, from table sugar to starches, can be digested and
converted into glucose, which is then sent throughout the body via
the bloodstream. Until relatively recently, digestion rate and
therefore blood glucose levels was thought to depend upon the
length of the saccharide chains of the carbohydrate being digested.
Thus, it was thought that sugars and simple carbohydrates would be
digested faster, and starches and other complex carbohydrates would
be digested slower. Although the government was never able to
propose an adequate definition of “complex
carbohydrates,” nor of “simple carbohydrates,” it
did seemingly acknowledge this assumption about the correlation
between chain length and digestion rate in the Food Guide Pyramid,
which has starchy carbohydrates at the base and sugars at the
top.[28]

Recently, scientists have questioned the relevance
of chain length to carbohydrate digestion rates. A study published
in November of 1978 found that blood glucose and insulin levels
were not different by any statistically significant amount between
ingestion of carbohydrates as monosaccharides, disaccharides, and
polysaccharides. The study concluded that dietary form in which
starch is administered, rather than chain length, was probably most
important in determining blood glucose and insulin levels.[29] Another study, this one in 1983, also found
similar evidence that so-called simple carbohydrates were digested
no faster than so-called complex carbohydrates. In this study,
subjects were given five meals, each containing similar amounts of
carbohydrates, but in different forms. The five test carbohydrates
were glucose, sucrose, fructose, wheat starch, and potato starch.
Glucose levels for sucrose (table sugar) were significantly
different from that of wheat starch, potato starch, and glucose.
Fructose had slightly lower glucose levels, sometimes achieving
significance, and sometime not. These researchers concluded that
table sugar did not raise blood glucose levels any more than most
other forms of carbohydrates.[30]

Despite this evidence, scientists have long known
that some carbohydrates cause greater changes in blood glucose
levels than others. This led researchers to the glycemic index, a
system of classifying carbohydrate-containing foods according to
their glycemic responses. Although glycemic indices vary, and
cannot be predicated based on saccharide chain length, there are
certain principles one can follow. In general, most highly refined,
starchy carbohydrates have a high glycemic index, and nonstarchy
vegetables, fruit, and legumes tend to have a lower glycemic index.
Eating fat or protein with your carbohydrates appears to lower the
glycemic index of the overall meal, but the glycemic response to
mixed meals can still be prediced from the glycemic index of the
constituent foods. The term “glycemic load” is also
frequently used to describe the effects of certain foods on blood
glucose levels. The glycemic load, defined as the weighted average
glycemic index of individual foods multiplied by the percentage of
dietary energy as carbohydrate, is used to describe the impact of
foods with different macronutrient compositions on glycemic
response.[31]

As discussed, meals high on the glycemic index or
glycemic load will cause the body to release more glucose into the
bloodstream than low-glycemic index foods. In fact, blood glucose
levels two hours after ingestion may be at least twice as high
after a high-glycemic index meal than a low-glycemic index meal
containing identical nutrients and energy (calories).[32] These high levels of blood glucose concentration
stimulate the pancreas to release insulin, which transports
nutrients into the cells of the body. Insulin also dictates energy
storage, basically where the calories consumed go and to what
degree. High levels of insulin can lead the body into storing
energy as body fat, with negative consequences.[33] Because of the rapid uptake of nutrients due to
high insulin levels, soon (after several hours) the energy is
absorbed and blood glucose levels fall rapidly, much more rapidly
than after low-glycemic index meals. Blood glucose levels fall so
far that the body goes into a hypoglycemic state where it needs to
elevate the levels. In an effort to achieve homeostasis and return
the blood glucose levels to normal, the body gets hungry and
signals for the person to eat again. Had the person eaten a meal
with a lower glycemic index, the hypoglycemic state would never
have occurred, and blood glucose levels would have remained more
stable over a longer period of time.[34] Put simply, the higher the glycemic index (more
accurately, load) of your meal, the sooner you will get hungry
again, even with the exact same amount of macronutrients and
calories.

All of this said about increased fat storage from
consumption of carbohydrates is mainstream, accepted food science.
That said, most food scientists believe that people gain weight
from eating more calories than they burn, and that it doesn’t
matter which macronutrient they get these calories from. That is to
say, if you eat more calories from any macronutrient (protein,
carbohydrates, or fat) than you burn, you will gain weight.
However, some recent studies have begun to challenge this notion
that a calorie is a calorie.[35]

We should pause here to examine why humans store
fat, and why some humans seem predisposed to store more fat than
others. The current mainstream hypothesis as to why some humans are
getting fatter in today’s society but some aren’t is
called the Thrifty Gene Hypothesis. This hypothesis supposes that
genes that lead to more fat storage provided an appreciable
advantage to our evolutionary ancestors. Those families with the
thrifty gene would store excess food as fat during times when food
was plentiful, and then rely on this fat storage for energy during
times of famine or when food is less plentiful. It’s easy to
see that those families without the gene might be more likely to
die off during periods of famine.[36]

Equally important, however, is that our ancestors
did not dine in restaurants or live sedentary lifestyles. They went
on hunts for meat, with hunts lasting for days and covering vast
territory. They traveled for miles to get to gather wild sources of
fruits, grains, and nuts. Because their chief sources of protein
were wild animals, they ingested less fat than we do, eating
animals raised in feedlots with much higher fat contents. Neither
did they eat highly refined carbohydrates, instead primarily eating
whole grains that had more fiber to slow digestion.[37] Thus, we see that evolution could be used to
support either the low-fat or the low-carbohydrate diets.

IV. The Scientific Basis for Four Modern
Recommended Diets

Now that we understand how the body processes
carbohydrates, let us move to the more controversial science that
each of these diets claims as evidence of their effectiveness at
weight loss and health improvements.

First, a quick note about agreements between the
scientists. All of the diets described above recommend moving away
from simple carbohydrates, which is difficult to define precisely
but usually means avoiding sugary foods and highly refined
carbohydrates such as white bread and those made with white flour.
These sugars and refined carbohydrates are usually devoid of
nutrients and, as discussed previously, cause blood glucose and
insulin levels to rise, usually causing one to be hungry again
before he/she normally would need more food. Instead of refined
carbohydrates, nearly all scientists agree that fiber-rich whole
foods are much healthier. Even better, according to all
nutritionists, are fruits and vegetables, although several of the
diets prefer that one choose vegetables and fruits with a low
glycemic index, to avoid rising blood glucose and insulin levels.
Everybody also agrees that omega-3 fatty acids are a healthy way to
lower the risks of coronary heart disease; these fats are
frequently found in cold-water fish such as salmon, and even those
advocating low-fat diets recommend consuming this type of fat. One
type of fat most experts think should be avoided is trans-fatty
acids; these fats are widely believed to cause heart
disease.[38]

A. The Low-Fat Diet

The chief advocate of a low-fat diet similar to
that proposed by the Dietary Guidelines for Americans and the USDA
Food Guide Pyramid for the last twenty years is Dr. Dean Ornish.
Dr. Ornish has sold over 25 million copies of his books on
reversing and preventing heart disease, and advocates a low-fat
high-carbohydrate diet rich in fruits and vegetables and whole
grains. Recognizing that fat has more than twice as many calories
per gram as carbohydrates, Dr. Ornish believes that people should
fill up on complex carbohydrates since gram for gram they
won’t consume as many calories. For reversing heart disease,
Dr. Ornish recommends an extremely low-fat diet with fat less than
10% of total daily caloric intake. For simple weight loss and heart
disease prevention, Dr. Ornish still advocates cutting back on fat,
but allows up to 15% of calories to come from fat.[39]

Dr. Ornish bases his diet on the simple premise
that a calorie is a calorie, whether it comes from protein,
carbohydrates, or fat. If we assume that people are going to eat
the same number of grams of food no matter what the macronutrient
composition, people will consume less calories if they eat low-fat
less-dense meals rather than high-fat calorie-dense meals. Since
fat has 9 calories per gram and carbohydrates and protein only have
4 calories per gram, people can eat twice as many grams of
carbohydrates than they can fat. Thus, a meal with 15 grams of
protein, 65 grams of carbohydrates, and 20 grams of fat would have
500 calories, whereas a meal with an equal number of grams of food
but a macronutrient mix of 30 grams of protein, 30 grams of
carbohydrates, and 40 grams of fat would have 600
calories.[40] According to Dr. Ornish, since you’ve
consumed 100 less calories, you’ll lose weight. Dr.
Ornish’s prescription for weight loss, in fact,
couldn’t be simpler- consume fewer calories than you burn
each day. “Here’s how you lose weight: 1. Burn more
calories. 2. Eat fewer calories. That’s it.”[41]

For evidence of effectiveness, Dr. Ornish cites to
a study he performed that had an experimental group of patients
with heart disease adopt a 10% fat, vegetarian high-carbohydrate
diet, exercise, and stress reduction techniques, comparing the
results of that group to a control group (also with heart disease)
that had more minor changes in their diet and no other lifestyle
changes. The low-fat group lost 23.9 pounds after one year, and
kept an average of 12.8 pounds off after 5 years. In contrast, the
control group’s weight changed little from the baseline. The
experimental group lowered their LDL (bad) cholesterol levels 40%
after one year, and LDL levels were still 20% lower than the
baseline after 5 years; the control group had their LDL cholesterol
levels decrease by 1.2% after one year, and 19.3% after 5 years.
The difference between the two groups after 5 years was not
statistically significant, possibly because 60% of the control
group, and none of the experimental group, took lipid-lowering
drugs between years 1 and 5. The drop in LDL cholesterol levels is
of note, because high LDL cholesterol levels are thought to be one
predictor of heart disease. There was no significant changes in
triglycerides, which are also widely considered to be another
predictor of heart disease. The low-fat group also experienced a
91% decrease in frequency of angina pectoris (chest pain) after one
year, and maintained a 72% reduction after 5 years. Control group
patients had a 186% increase in angina after one year, but then
three of the control group patients underwent coronary
angioplasties, with the result being a 36% decrease in control
group chest pain after five years, not statistically different from
the experimental group. Interestingly, HDL (good) cholesterol
levels also decreased for the experimental group, but the ratio of
LDL to HDL levels was still improved. While low levels of LDL
cholesterol help prevent heart disease, as do high levels of HDL
cholesterol, the most important factor, according to Dr. Ornish and
most doctors, is the ratio of good to bad cholesterol, which
improved for the low-fat vegetarian diet group. Lastly, 20 of 28
(71%) of the experimental patients maintained the lifestyle changes
for 5 years, and 15 of 20 (75%) of patients in the control group
made more minor changes and completed the 5-year follow-up. This is
important in that a frequent criticism of the low-fat diet Dr.
Ornish prescribes is that it is too hard to follow and people give
up easily.[42]

Speaking just in terms of weight loss, Dr. Ornish
believes that any diet that restricts calories can cause weight
loss, since a calorie is a calorie. He advocates a low-fat diet
because of the health benefits associated with such a diet,
including a decreased risk of heart disease and improved
cholesterol levels. On his point that weight loss can occur
regardless of macronutrient composition of the diet, he does have
some studies to back up his claim. Noakes and Clifton divided
subjects into three groups. The first group ate a low-fat diet with
fat less than 10% of daily calories, and saturated fat only
accounting for less than 3% of daily calories. The second group had
a high saturated fat diet, with total fat intake at 32% of
calories, and saturated fat intake at 17% of calories. The third
group had a high unsaturated fat diet, with fat intake at 32% of
calories and 6% of calories coming from saturated fat. All three
groups consumed the same number of calories, and all three lost an
average of 9.7% of their weight over 12 weeks, with no significant
differences between groups. Interestingly, LDL (bad) cholesterol
decreased roughly 20% with the low-fat and high-unsaturated fat
groups, but only decreased 7% for the saturated fat group, which is
significant at the .05 level. This would seem to support Dr.
Ornish’s claim that any calorie-restricted diet can cause
weight loss, but that a low-fat diet has other health benefits over
a diet high in saturated fat, such as the Atkins diet.[43]

Similarly, Alford et al performed an experiment
with three groups of women on 1200 calorie diets, with the groups
eating diets that contained either 25%, 45%, or 75% carbohydrate.
After 10 weeks, no significant differences were found between
groups for weight loss, body composition, cholesterol,
triglycerides and percent body fat. Alford et al concluded:
“Selection of a weight reduction diet can be designed around
preferred food patterns and nutrition needs of individuals rather
than a proportion of the energy provided by carbohydrate in healthy
adult women.”[44] This would seem to prove Dr. Ornish’s point
that a calorie is a calorie, and he would argue the 75%
carbohydrate group had less hunger cravings than the 25%
carbohydrate group.

As even more evidence of there being no significant
difference in weight loss between dietary compositions, Golay et
al. put subjects on a 1200 calories diet, some with 25% of calories
from carbohydrates, some with 45% of calories from carbohydrates.
Weight loss and fat loss occurred similarly for both groups, and
there were also similar decreases between groups for waist/hip
ratio, blood glucose levels, cholesterol levels, and triglycerides
levels. The authors concluded: “Neither diet offered a
significant advantage when comparing weight loss or other,
metabolic parameters over a 12 [week] period.”[45]

B. The Low-Carbohydrate (Atkins) Diet

Largely due to the fact that it has been so long
ignored by the mainstream food scientists, there are not as many
studies on the Atkins diet as there are on the low-fat diets.
Nonetheless, low-carbohydrate diets are being increasingly studied,
as doctors find themselves with little information to give patients
asking about the Atkins diet.[46]

One of the most basic arguments made by Atkins
proponents doesn’t involve science at all, but rather an
argument based on correlation. In 1980, the U.S. Department of
Agriculture made the official recommendation in the U.S. Dietary
Guidelines For Americans that fat should account for no more than
30% of daily calories, and the Food Guide Pyramid still prominently
displays this limit on the front cover of the Food Guide Pyramid
brochure. The theory was that fat was making Americans fat, and
that carbohydrates should replace the fat that we stop eating.
Since then, Americans have reduced their average fat intake from
40% of daily calories to 34%, but heart disease incidence
hasn’t declined.[47] When the Food Guide Pyramid came out in 1992 with
its recommendation of 6 to 11 servings of grains, breads, and
cereals, 56% of American adults were overweight; today, 64% of
Americans are overweight, despite the increase in percentage of
calories from fat. The rate of obesity has fared even worse- since
1991 the rate of obesity has increased by 74%, with 21% of the
adult population obese today.[48] Atkins supporters ask why Americans started
getting fatter right after the USDA Food Guide Pyramid came out
recommending increased carbohydrate consumption and less fat
consumption. Dr. Ornish points out that actual fat grams consumed
has increased over the last 10 years, but fat as a percentage of
calories has decreased because we have so drastically increased our
daily caloric intake. Also, Dr. Ornish think 30% of calories from
fat is still too high, and recommends it being lowered to 10 to
15%.[49]

Despite the relative ignoring of the Atkins diet by
most health professionals, some scientific studies have been
performed, and more studies are currently under way. First, a note
about the Atkins diet is in order. Dr. Atkins recommends consuming
very low levels of carbohydrates (less than 50 grams) the first
week of his diet, which puts the body in a state of ketosis.
Ketosis, which can also be caused by prolonged fasting, is when
whole-body metabolism shifts towards obtaining a greater percentage
of energy from fat stores, which can result in the production of
ketone bodies in the liver. Ketones, which are large protein
molecules, can serve as an alternative fuel for tissues to spare
carbohydrate and protein. Ketone body production indicates that fat
metabolism has been accelerated and that all the enzymes involved
in the metabolism of fat are operational.[50] There have been some concerns that ketones are
hard for the kidneys to process, and that ketosis may increase the
risk of kidney stones.

One of the more recent studies involving the Atkins
diet, led by University of Pennsylvania’s Gary Foster,
divided overweight subjects into two classes, putting one on a
high-carbohydrate diet and another on a low-carbohydrate diet.
After three months, the low-carbohydrate group had lost an average
of 19 pounds, 10 more than people on the standard high-carbohydrate
diet. Even better was the differences in cholesterol; the Atkins
dieters’ bad cholesterol did go up seven points, but their
good cholesterol rose almost 12 points. Changes in the
high-carbohydrate group weren’t as dramatic; their bad
cholesterol went down slightly while good cholesterol levels were
unchanged. Most significantly, the Atkins dieters’
triglycerides dropped 22 points, but the high-carbohydrate
group’s didn’t change.[51]

One study found that increased carbohydrate intake
as a percentage of daily calories lowered HDL (good) cholesterol
levels. More specifically, the study found HDL levels were
positively correlated with fat intake and saturated fatty acid
intake, but negatively correlated with carbohydrate intake and
simple carbohydrate intake, all significant at the .001
level.[52] Thus, this study would seem to suggest that
consumption of carbohydrates would lower good cholesterol and
possibly lead to an increased risk of heart disease. Similarly,
studies have found that a diet low in fat and high in carbohydrates
may raise triglyceride levels,[53] and may actually increase LDL (bad) cholesterol
levels.[54]

Another study looking favorable for the Atkins diet
tried to discover the effect of a low-carbohydrate ketogenic
(meaning that it induces ketosis) diet on healthy men who are not
overweight and don’t have high cholesterol. The study forced
the men to keep their weight steady while on the low-carbohydrate
diet (30% of calories from protein, 8% from carbohydrate and 61%
from fat), and the control group maintained their previous diet
(17% of calories from protein, 47% from carbohydrate and 32% from
fat). After six weeks, there were no changes in blood profiles for
the control group, but HDL (good) cholesterol had increased 11.5%
for the low-carbohydrate dieters (p=.066). This increase in HDL
cholesterol is important in that it cannot be attributed solely to
the weight loss, as the researchers forced the men to maintain
their previous weight.[55]

Another study involving healthy, normal-weight men
had an astonishing finding. Volek et al. had 12 healthy men switch
from their normal high-carbohydrate diet (48% of calories from
carbohydrates, 32% from fat) to a very-low-carbohydrate diet (8% of
calories from carbohydrate, 61% from fat), and 8 men remained on
their normal diet as a control group. After six weeks, there were
no significant changes in the control group. The low-carbohydrate
group, however, lost an average of 3.3 kg of fat (p<.05),
despite consuming more calories than the high-carbohydrate group
(2335 to 2190 calories per day, respectively). The low-carbohydrate
group also had an increase in lean body mass of 1.1 kg, suggesting
that very-low-carbohydrate diets favor loss of fat, and help to
preserve lean muscle tissue over longer periods of time. The fact
that 12 normal, healthy men lost fat and increased lean body mass
while consuming more calories than the control group, without any
change in physical activity, suggests that the
very-low-carbohydrate ketogenic Atkins diet deserves further study,
as the sample size of 12 and 8 men was rather small.[56] Although the precise mechanism for how the body
lost fat and gained lean body mass is not yet understood, the test
subjects also exhibited a decrease in insulin levels of 34%, which
explained 70% of the variability of fat loss for the
very-low-carbohydrate group. Studies like this one may also cast
doubt on the theory that all calories are equivalent, since the
low-carbohydrate group consumed more calories yet lost more
fat.

C. The Zone Diet

Dr. Sears and his Zone diet also have scientific
studies proving effectiveness. One study divided women into two
groups- one consuming 40% of daily calories as carbohydrate, 30% as
protein, and 30% as fat, and the other consuming 55% of calories as
carbohydrate, 15% as protein, and 30% as fat.[57] This ratio of 40% carbohydrate, 30% protein, and
30% fat is what the Zone diet recommends for optimum blood glucose
and insulin levels.[58] The Zone dieters ate 125 grams of protein per day,
171 grams of carbohydrates, and 50 grams of fat; the high
carbohydrate group ate 68 grams of protein per day, 240 grams of
carbohydrate, and 50 grams of fat, giving both groups roughly 1650
calories per day. After 10 weeks, weight loss was similar between
the two groups, but insulin levels two hours after ingestion of a
meal were significantly (p<.05) higher for the high-carbohydrate
group than the Zone group.[59] We have already discussed how greater insulin
levels after eating causes increased absorption of nutrients into
the body, causing the subject to feel hungry again sooner, and how
insulin encourages the storage of extra energy as fat. Thus, the
Zone diet effectively stabilized blood glucose levels and reduced
the insulin response to meals.[60]

Another study involving the Zone diet sought to
explore changes in body composition during weight loss and changes
in blood profiles between diets. Once again, women were separated
into two groups, the first consuming a diet of 41% carbohydrate,
30% protein, and 29% fat, the other (high-carbohydrate) group
consuming 58% carbohydrate, 16% protein, and 26% fat. Daily
calories consumption was equal for the two groups at roughly 1650
calories. Both groups lost about 7 pounds of weight, but the ratio
of loss of fat to loss of lean body mass was significantly improved
for the Zone dieters, at 6.36 to the high-carbohydrate
group’s 3.92 (p<.05). “The ratio of fat/lean loss
demonstrated that the higher protein [Zone] diet partitioned a
significantly greater percentage of the weight loss to body fat
while sparing lean tissue [such as muscle].”[61] The two groups lost a similar amount of total
cholesterol (about 10%) and of LDL (bad) cholesterol, with neither
group showing a significant change in HDL (good) cholesterol. Women
in the high-carbohydrate group had higher insulin responses to
meals, and the Zone women reported greater levels of satiety. The
Zone diet thus appears to help preserve lean body mass while losing
fat, and, as before, aids in the stabilization of blood glucose and
insulin levels.

Another study limited subjects to either a
high-carbohydrate diet (58% of calories from carbohydrate, 12% from
protein, 30% from fat) or a diet similar to the Zone diet (45%
carbohydrate, 25% protein, 30% fat). Weight loss after six months
was 5.1 kg in the high-carbohydrate group and 8.9 kg in the Zone
group, with the Zone group’s weight loss significantly
greater (p<.001). Fat loss amounted to 4.3 kg for the
high-carbohydrate group and 7.6 kg for the Zone group, again a
significant difference (p<.0001). This study is especially
important since it wasn’t conducted in a clinically
controlled setting but rather allowed the subjects to go home and
eat as many calories as they wanted. Thus, the Zone diet appears to
cause greater weight loss and fat loss when calories are not
limited to a specific number as with previous studies.[62]

D. The SugarBusters Diet

The SugarBusters diet, with its emphasis on the
glycemic index of foods, has also received attention from the food
scientists. One study first put subjects on either the American
Heart Association (AHA) Step 1 diet (similar to that recommended by
USDA Food Guide Pyramid, restricting fat intake to 30% of calories
and saturated fat to 10%) or a low-glycemic
index-low-fat-high-protein diet. In the first stage of the
experiment, subjects were allowed to eat as many calories as they
wanted, until they felt full. Subjects on the AHA Step 1 diet
experienced an increase of triglyceride levels of 28% (p<.05),
and a 10% reduction in HDL (good) cholesterol levels (p<.01),
resulting in a significant increase in cholesterol:HDL-cholesterol
(p<.05), this ratio being commonly used to assess the risk of
coronary heart disease. In contrast, subjects on the low-glycemic
index-low-fat-high-protein diet spontaneously decreased daily
caloric consumption 25% (p<.001), and decreased triglyceride
levels 35% (p<.0005). In the second phase of the experiment,
some subjects were fed the AHA Step 1 diet, but calorie consumption
was restricted to the same as that consumed by the low-glycemic
index-low-fat-high-protein diet group. These subjects experienced a
marked increase in hunger (p<.0002) and a significant decrease
in satiety (p<0.007) as opposed to the low-glycemic
group.[63]

In another study, 107 obese but otherwise healthy
children were put on either a low-fat or low-glycemic index diet.
The body mass index decreased 1.53 points in the low-glycemic index
group, and only an insignificant .06 points, with the difference
significant at the .001 level. Body weight decreased 2.03 kg for
the low-glycemic index group and increased 1.31 kg for the low-fat
group, with the difference again significant at the .001 level. The
differences between the two diets remained significant during
multivariate analysis as well, controlling for BMI baseline,
baseline weight, age, sex, and ethnicity (p<.01).[64] Again, we see that the low-glycemic index diet
resulted in a significant decrease in body mass index and body
weight over the standard low-fat diet.

In a multiple linear regression reanalysis of a
cross-sectional study, a relationship was found between HDL (good)
cholesterol levels and dietary glycemic index. Total cholesterol
and LDL (good) cholesterol levels were not influenced by glycemic
index or any other component of dietary carbohydrate or fat.
“In this study, only body-mass index, smoking, and the
glycemic index of the diet were identified as potentially
modifiable risk-factor variables for HDL-cholesterol
concentration.” Thus, it would seem that modifying
one’s diet based on the glycemic index is the best, and
perhaps only dietary, way to increase HDL cholesterol levels,
thereby improving the LDL:HDL cholesterol ratio.[65]

A recent study, studying the dietary habits of over
75,000 U.S. women with a 10 year follow-up, found that glycemic
load was directly associated with risks of coronary heart disease
after adjusting for age, smoking status, total energy intake, and
other coronary disease risk factors. Interestingly,
“[c]arbohydrate classified by glycemic index, as opposed to
its traditional classification as either simple or complex, was a
better predictor of CHD [coronary heart disease] risk.” The
authors concluded: “These epidemiologic data suggest that a
high dietary glycemic load from refined carbohydrates increases the
risk of CHD [coronary heart disease], independent of known coronary
disease risk factors.”[66]

E. A Convergence of Food Science?

Given all these seemingly conflicting studies, one
may wonder if there is any agreement amongst all the studies and
individual diets. The great majority of the studies supporting all
of these diets seems to indicate that highly refined carbohydrates
(such as white bread, white rice, and soft drinks with
high-fructose corn syrup) generally increase fat storage due to
their high glycemic indices (or glycemic loads). Since we know that
being overweight or obese greatly increases the risks of having
heart disease, we can safely conclude that the science agrees that
highly refined carbohydrates are bad for us.

V. Analysis of the U.S. Government’s Efforts
and Response to Glycemic Index Studies

A. The Food Guide Pyramid, Dietary Guidelines, and
“Whole Grains”

Now knowing that refined carbohydrates are not
healthy, especially in large quantities due to an even greater
glycemic load and consequently greater insulin response, let us
examine the USDA Food Pyramid and the Dietary Guidelines for
Americans, 5th Edition. As previously noted, the USDA
Food Guide Pyramid made its debut in 1992 as an easy and quick way
for Americans to visualize and absorb the dietary advice of the
Dietary Guidelines for Americans. The Food Guide Pyramid was last
updated in 1996, and despite the plethora of scientific evidence
available by then showing the dangers and negative health
consequences of highly refined carbohydrates the pyramid still
fails to differentiate between highly-refined and whole-grain
carbohydrates.[67]

One may wonder why the government would ignore the
concerns of food scientists over foods high in glycemic index.
Indeed, considering that the glycemic index was developed in 1981
as a better way to classify carbohydrates rather than classifying
them by the saccharide chain length, one would assume the concept
of glycemic index was rather prominent by 1992, but definitely by
the time of the Food Guide Pyramid update of 1996.[68] To understand why the USDA would ignore concerns
over the glycemic index of highly refined carbohydrates, one needs
to remember that the government at that time was focusing its
efforts on reducing the amount of fat that Americans consumed, as
evidenced in both the Food Guide Pyramid and the Dietary Guidelines
for Americans. Also, the developers of the Food Guide Pyramid
wanted it to be understandable and memorable, especially for
uneducated Americans who probably need the nutrition advice the
most. Given these priorities, it is little wonder that the Food
Guide Pyramid fails to distinguish between highly refined
carbohydrates and whole grain carbohydrates- the USDA had too many
other concerns to bother with also making this distinction in an
easy-to-use memorable graphic.[69]

What seems harder to understand is why the brochure
accompanying the USDA Food Guide Pyramid fails to distinguish these
sources of carbohydrates. Although this brochure still needed to be
easy to understand, it was 17 pages long and this distinction
easily could have been made without complicating things too
much.[70] Indeed, the only time the brochure appears to make
a distinction is when it states: “To get the fiber you need,
choose several servings a day of foods made from whole grains, such
as whole-wheat bread and whole-grain cereals.”[71] While it is true that whole grain foods do contain
more fiber than refined carbohydrates, no mention is made of the
lower glycemic index of these foods and the accompanying benefits
of choosing foods low in glycemic index. Considering that 60% of
Americans are familiar with the Food Guide Pyramid,[72] a simple paragraph in the brochure discussing
choosing whole wheat bread over white bread, brown rice over white
rice, whole-grain pasta over refined pasta, etc., would have been
tremendously helpful in assisting Americans to lose weight and stay
healthy.

The Dietary Guidelines for Americans,
5th Edition, does do a much better job of encouraging
the consumption of whole grain foods. Page 20 of the brochure is
devoted almost entirely to encouraging an increased intake of whole
grain foods. The first paragraph describes why, according to the
government, people should choose whole grains:

Choose a variety of grains daily, especially whole
grains

Foods made from grains (wheat, rice, and oats)
help form the foundation of a nutritious diet. They provide
vitamins, minerals, carbohydrates (starch and dietary fiber), and
other substances that are important for good health. Grain products
are low in fat, unless fat is added in processing, in preparation,
or at the table. Whole grains differ from refined grains in the
amount of fiber and nutrients they provide, and different whole
grain foods differ in nutrient content, so choose a variety of
whole and enriched grains. Eating plenty of whole grains, such as
whole wheat bread or oatmeal (see box
11 ), as part of the healthful eating patterns described by
these guidelines, may help protect you against many chronic
diseases. Aim for at least 6 servings of grain products per
day—more if you are an older child or teenager, an adult man,
or an active woman (see box
7 )—and include several servings of whole grain foods.
See box
8 for serving sizes.[73]

Several aspects of this paragraph are interesting.
First, like the Food Guide Pyramid brochure, the Guidelines
recommend consuming whole grain foods, but only for one reason.
They both fail to note that whole grain carbohydrates have a lower
glycemic index and thus help to prevent an insulin rush which
usually leads to increased body fat. Second, the paragraph is of
note because it recommends choosing a variety of “whole
and enriched” grains (emphasis added). Had the
committee carefully read the reports on the glycemic index of
refined carbohydrates, it would have recommended whole grains
over enriched grains. Lastly, the paragraph concludes by
recommending to consume at least 6 servings of grain products per
day, and to include several servings of whole grain foods. When the
recommendation for grains is 6 to 11 servings per day, only
recommending several servings of whole grain foods means that most
of the carbohydrates people get will be from enriched grains, most
likely in the form of high-glycemic index refined carbohydrates.
According to those food scientists associated with the glycemic
index, this is not a message that should be conveyed to the
American public.

Americans seem to know the Food Guide Pyramid, and
they have taken its advice to heart. From 1970 to 1994, the intake
of wheat flour increased by 35%, corn flour by 79%, grain mixtures
by 115%, high carbohydrate snacks by 200%, and ready-to-eat cereals
by 41%. Today, 78% of total dietary carbohydrate in the USA is in
the form of grains, grain products and sweeteners.[74] Given this massive consumption of carbohydrates,
one would expect Americans to be consuming whole grain foods as
well as refined carbohydrates, but that is evidently not the case.
A 1995 study found that dietary intake of whole grain foods
averaged only one-half serving per person per day.[75] Interestingly, the Dietary Guidelines Advisory
Committee noted the increased health benefits of substituting whole
grain foods for refined grain foods, but did not understand itself
why these benefits occurred. “Specific mechanism that explain
the associations of higher intakes of whole grains with reductions
of chronic disease risk are not defined well.” The Committee
also noted that the “risk reduction in the cited studies [on
coronary heart disease and hypertension] was associated with higher
levels of whole grain intake and could not be explained by
adjustments for fiber intake. This suggests that components of
whole grain nutrients other than fiber help reduce risk for
coronary heart disease.”[76]

The Committee fails to even mention that one likely
reason for the beneficial effects of substituting whole grain foods
for refined grain foods is a reduced glycemic index. This would, of
course, help explain the decrease in risk of coronary heart disease
and hypertension. That the Committee would fail to note this aspect
of whole grain foods is peculiar, especially since the glycemic
index has been around since 1981. Nonetheless, since the previous
edition of the Dietary Guidelines did not even include advice about
choosing whole grain foods over refined grain foods, the
5th Edition of the Dietary Guidelines should be seen as
a significant step towards the recognition of the beneficial health
effects of eating a low-glycemic index diet.

As for the Dietary Guidelines and Food Guide
Pyramid recommending that Americans consume both whole grain foods
and refined grain foods, that can be explained by the USDA’s
process to determine the amounts of each food group to include in
the food guide:

Step 5. Determination of the Numbers of
Servings.

Determination of the amounts of each food group to
include in the food guide was a two-phase process. The first
focused on concerns about nutrient adequacy and the second focused
on concerns about moderation. The first phase involved determining
the number of servings from each nutrient-bearing food group and
subgroup needed to meet the nutritional goals for protein,
vitamins, and minerals.[77]

The second phase was supposed to focus on food
components for which moderation was a concern. However, the USDA
calculated the number of calories necessary to achieve the desired
levels of the vitamins, minerals, and protein, subtracted that from
the daily caloric targets, and allowed the remainder to be from
fats and sugars. Thus, when the USDA was supposed to be concerned
with moderation, it really was only concerned with moderation of
fats and sugars, not moderation of refined carbohydrates.

The USDA’s process of first ensuring adequate
protein, vitamin, and mineral intake and then worrying about
moderation practically guarantees that enriched, highly refined
grain foods will be over-emphasized in the Food Guide Pyramid.
Interestingly, the problem of malnutrition from a lack of vitamins
or minerals is no longer a pressing problem in America, nor was it
when the Food Guide Pyramid and Dietary Guidelines were created.
[78] Instead, the most pressing nutrition and health
problem in America today would have to be either coronary heart
disease or obesity, both of which are caused (at least in part) by
nutritional problems that have nothing to do with vitamin and
mineral intake. Thus, we see that the Food Guide Pyramid reflects,
at least in part, outdated priorities that address problems long
since overshadowed by larger, more serious problems. Should the
USDA change its process of determining servings to reflect the fact
that obesity and coronary heart disease are much worse problems in
America today than vitamin and mineral deficiencies, the amount of
whole grain foods recommended would probably be increased while
decreasing the amount of vitamin-enriched highly-refined grain
foods recommended.

B. The “Complex Carbohydrate”
Controversy

As evidenced by the Advisory Committee notes, the
federal government is aware that some forms of carbohydrates are
healthier than others. In the past, many food scientists used to
divide carbohydrates into two groups, simple carbohydrates and
complex carbohydrates. The term “simple carbohydrate”
was usually used to refer to foods that had a high sugar content
and were thought to be unhealthy. The term “complex
carbohydrate” was used to refer to those carbohydrates that
didn’t contain very many sugars and were thought to be
healthy. The USDA Food Guide Pyramid recommends breads, cereals,
rice and pasta precisely because they “provide complex
carbohydrates (starches), which are an important source of energy,
especially in lowfat diets.”[79]

In an effort to aid consumers in choosing foods
with healthy carbohydrates rather than simple carbohydrates,
Congress passed the Nutrition Labeling and Education Act of 1990,
which gave FDA the authority to require the now-ubiquitous food
labels.[80] Congress originally required the following
nutrients to be included in the food label: total fat saturated
fat, cholesterol, sodium, total carbohydrates, complex
carbohydrates, sugars, dietary fiber, and total protein.[81] The Act gave the Secretary of the DHHS the
authority to require other nutritional values on the label, and
also allowed the Secretary to remove the information required by
Congress to be on the label if the Secretary determined that the
information relating to that nutrient is not necessary to assist
consumers in maintaining healthy dietary practices.[82] It was expected that the Secretary would provide
definitions of the nutrients at its discretion, consistent with
scientific principles.[83]

As alluded to earlier, the definition of complex
carbohydrate heretofore had been rather vague and inconsistent.
Therefore, the FDA had considerable trouble creating a suitable
definition for “complex carbohydrate.” The FDA wanted
to provide a definition that was consistent with the physiological
effects attributed to complex carbohydrates in the various
scientific reports, but none of the reports had provided a chemical
definition of the term, and there was no commonly accepted chemical
definition. Therefore, FDA tried to provide a chemical definition
that would enable consumers to receive the health benefits commonly
ascribed to “complex carbohydrates.”

FDA proposes that "complex carbohydrate" be defined
as the sum of dextrins and starches. Thus, complex carbohydrate, as
defined, includes those carbohydrate components that contain 10 or
more saccharide units (exclusive of dietary fiber). FDA is aware
that including dextrins within the definition of "complex
carbohydrate" may result in the classification of certain
components of a few nutritive sweeteners as complex carbohydrates.
The agency, therefore, requests comments on this proposed
definition and solicits suggestions for alternative definitions of
"complex carbohydrate."[84]

The FDA received numerous complaints about this
proposed definition. Many comments pointed to the lack of existing
analytical methodology to support the proposed definition, raising
concerns about the feasibility of compliance and the economic
burden of developing methods and databases. Others criticized the
FDA on the basis that the cutoff at 10 saccharide units was
arbitrary, as there are no known nutritional or physiological
differences, nor a methodological justification, to make a
distinction between polysaccharides smaller than 10 saccharide
units and those with 10 or more saccharide units. Listening to
these complaints, FDA decided to abandon trying to define
“complex carbohydrate,” and instead created a new
category of “other carbohydrate.”[85] Replacing “complex carbohydrate,”
“other carbohydrate” is defined as the difference
between total carbohydrate and the sum of dietary fiber and sugars
or, if sugar alcohol is declared, the difference between total
carbohydrate and the sum of dietary fiber, sugars, and sugar
alcohol.[86]

The FDA’s inability to define complex
carbohydrate is significant, since numerous studies tout the myriad
health benefits of complex carbohydrates and Americans, hearing
about these studies, wish to obtain these health benefits. They
read in the USDA Food Guide Pyramid brochure that they should
replace fats and sugars with complex carbohydrates, yet when they
go to the grocery store to purchase foods high in complex
carbohydrates they run into a problem. Without having complex
carbohydrate grams listed in the food label, consumers are unaware
whether any given food will provide the health benefits of complex
carbohydrates to them or not. Thus, even consumers wishing to
increase their complex carbohydrate intake cannot, under current
regulations, just by looking at the food label; instead, they must
search the ingredients list for whole grain foods such as whole
wheat, brown rice, and pearl barley. Given the emphasis on complex
carbohydrates throughout the Food Guide Pyramid, forcing consumers
to memorize key ingredients for what may amount to “complex
carbohydrates” seems unnecessarily difficult.

Nonetheless, because the Secretary is given the
discretion to determine whether inclusion of “complex
carbohydrate” in the food label would assist consumer in
maintaining healthy dietary practices, any legal challenge would
almost certainly fail. Courts will defer to the Secretary’s
expertise, and there is no litigation private parties can bring
that would likely result in forcing the Secretary to create a
definition of “complex carbohydrates.”

Given the courts’ usual deference to agency
decisions involving their particular expertise, and given that the
FDA did take comments on the proposal and explained their rationale
behind choosing to change “complex carbohydrate” to
“other carbohydrate” in their final rule, any legal
challenge to that action faces a stiff uphill battle.

C. The Definition of
“Carbohydrate”

Not only did FDA have to try to define complex
carbohydrate, it also had, as a preliminary matter, to define the
term “carbohydrate” itself. To do this, FDA relied on
the pioneering work of W.O. Atwater, who first described the
process of determining carbohydrate content of foods by difference.
The FDA adopted Atwater’s method, and currently defines total
carbohydrate by difference:

Total carbohydrate content shall be calculated by
subtraction of the sum of the crude protein, total fat, moisture,
and ash from the total weight of the food. This calculation method
is described in A. L. Merrill and B. K. Watt, "Energy Value of
Foods--Basis and Derivation," USDA Handbook 74 (slightly revised
1973) pp. 2 and 3, which is incorporated by reference in accordance
with
5 U.S.C. 552(a) and 1 CFR part 51 (the availability of this
incorporation by reference is given in paragraph (c)(1)(i)(A) of
this section).[88]

Thus, under current FDA definitions, anything that
isn’t protein, fat, moisture or ash in a food, must be by
definition carbohydrate. Again, the agency based this definition on
accepted scientific principles, so its choice of definition is to
be accorded great deference by the courts. This definition of
carbohydrate worked well for quite a while, but because of the
recent increased focus on reducing carbohydrate consumption (or
high glycemic index carbohydrate consumption) the definition has
been at the heart of some controversy.

The huge surge in popularity of low-carbohydrate
diets such as the Atkins diet inevitably led to the development of
new products intended to capitalize on the craze. Numerous
companies began selling low-carbohydrate meal replacement bars,
with the first big seller being Carbolite’s sugar-free
chocolate bar. The chocolate bar, which was first produced in 1999,
was so popular that orders went from 10,000 to 1 million in just
two months. In 2000, Carbolite persuaded 7-Eleven to place the bar
next to candy bars such as Snickers and Milky Way, and the bar
became the chain’s number 3 seller. Dr. Atkins has his own
nutritional line, Atkins Nutritionals, which sold about $35 million
in 1999.[89] Indeed, seeing the potential for huge sales,
numerous companies have gotten in the business of selling
low-carbohydrate bars: Atkins Nutritionals, Carbolite, EAS, Country
Life/Biochem, American Body Building, Next Proteins, Solid Protein,
Optimum Nutrition, and various smaller companies. In short, by
2000, if you wanted to sell meal replacement bars, you needed a
low-carbohydrate version, and every major company was either
already selling them or looking to start selling them.

The problem was that these low-carbohydrate meal
replacement bars weren’t actually low in carbohydrates. The
companies all produced bars claiming to have a few grams of
carbohydrate or less, and on the food label they would only list
several grams of carbohydrate under the “Total
Carbohydrate” heading. However, most of the products would
have a small footnote under or near the food label explaining that
the product contained a carbohydrate-substitute, usually glycerin,
oligofructose, sugar alcohols, and/or malitol. For example, the
wrapper for the Designer Whey Protein Bar (Chocolate Triplemint
flavor) manufactured by Next Proteins lists only 7 grams of
carbohydrates on the food label; under the food label is the
statement: “This product contains glycerine. Glycerine is not
a carbohydrate but has a caloric value of 4.32 calories per
gram.”

Most labels did not include the grams of the
carbohydrate-substitute on the wrapper, but very astute consumers
could calculate the grams of the carbohydrate-substitute; to do so,
one needed to add up the calories from the grams of fat, protein,
and listed carbohydrate (of course, one would need to know that
protein and carbohydrates have 4 calories per gram, and fat 9
calories per gram), and then subtract that number from the total
calories listed a the top of the food label. That would give the
calories from the carbohydrate substitute, and one could then find
the number of grams by dividing the calories by the energy density
of the substitute, usually around 4 calories per gram. In the
Designer Whey example, the bar lists 7 grams of fat, 7 grams of
carbohydrates, and 30 grams of protein. This would give us
(7*9)+(7*4)+(30*4) or 211 calories accounted for in the food label.
Since the top of the label gives total calories of 250, we know
there are 250-211, or 39 calories from glycerine. Dividing the 39
calories by 4.32 calories per gram, we find that there are roughly
9 grams of glycerine in our protein bar.

Given the FDA’s definition of carbohydrate
being everything that’s not protein, fat, ash, or moisture,
one would have a hard time excluding glycerine from the
carbohydrate content. The makers of the low-carbohydrate bars
claimed, sometimes on the wrapper itself, that these carbohydrate
substitutes did not count as carbohydrates because they
didn’t raise blood glucose levels, which is what makes normal
carbohydrates so unhealthy. Although there is little evidence in
the public domain of the impact of these carbohydrate substitutes
on blood glucose levels, given that the bars implementing these
carbohydrate substitutes do have lower glycemic loads than other
bars not using them, we must assume that these carbohydrate
substitutes do, indeed, have a minimal impact on blood glucose
levels. Nonetheless, the FDA definition of carbohydrates does not
mention blood glucose levels, and so the stage was set for a
showdown between the bar manufacturers and the FDA.

In mid-2000 the FDA issued warning letters to all
the manufacturers of these low-carbohydrate bars, warning them that
the products were misbranded under the Federal Food, Drug, and
Cosmetic Act because the “low carbohydrate” claim was
an unauthorized nutrient content claim, and because the glycerine
was not included as a carbohydrate. As one FDA warning letter put
it, “Glycerine is a carbohydrate. ... We advise that
glycerine must be included in the value declared for “Total
Carbohydrate.”[90]

The various low-carbohydrate bar manufacturers were
clearly not happy with the FDA’s decision, but most of the
large manufacturers have started complying with the decision. As
with dietary supplements, smaller companies that have little to
lose are refusing to update their labels, remaining in violation of
the FDA’s decision. One such bar clearly in violation of the
Federal Food, Drug, and Cosmetic Act as interpreted by the FDA is
Biochem’s Ultimate Lo Carbohydrate Bar. As if the name
wasn’t in violation of the law’s prohibition against
unauthorized implied nutrient claims, the bar’s front says
prominently “Only 2g Carbohydrates!” The food label on
the back also lists only 2 grams of carbohydrates under
“Total Carbohydrates,” and there is a small footnote
noting that glycerine has a caloric value of 4.32 calories per
gram. Because companies such as Biochem are small and only
manufacture this particular bar, they will probably not comply with
the FDA mandate until absolutely forced, creating unfair
competition for the larger manufacturers that have already started
to comply.

The Atkins Nutritionals website discusses their
approach to complying with the FDA decision, which is pretty
typical for most of the larger companies.[91] Atkins Nutritionals changed the front label to
read that there are only 2 grams of Net Carbohydrates in this
product. Let us use the Atkins Chocolate Mocha Crunch Advantage Bar
as an example. On the back, the carbohydrate substitutes glycerine
and malitol are included in the “Total Carbohydrates”
portion, as well as fiber, for a total of 19 grams of carbohydrate
in the food label. The Net Carbohydrates sidebar has the 11 grams
of polydextrose/fiber subtracted, as well as the 4.5 grams of
glycerine, leaving only 3.5 grams of Net Carbohydrates. Atkins says
that these are the grams of carbohydrate which should be closely
monitored, as they are the ones with a significant impact on blood
glucose levels, spikes of which can lead to overeating and
obesity.

Interestingly, all three of the diets profiled in
this paper (the Atkins diet, the Zone diet, and the SugarBusters
diet) agree that keeping blood glucose levels low and stable is an
important component of weight loss. However, the FDA’s
decision to include these carbohydrate substitutes as carbohydrates
has made it more difficult for consumers to watch their blood
glucose levels and to follow these diets. Nonetheless, the
FDA’s definition of carbohydrate is based on scientific
research performed by Atwater years ago, and was based on accepted
science, so it seems virtually impossible for the companies to
challenge the decision on administrative law grounds. The FDA
could, of course, try to define carbohydrates differently in the
future, so that those people wishing to watch their blood glucose
levels (which includes diabetics) would have an easier time of it.
One possible definition would be to provide a glycemic index
cutoff, so that those ingredients which don’t increase blood
glucose levels would not count towards the carbohydrate content. As
FDA notes, its original proposal for defining complex
carbohydrates, using saccharide chain length, wouldn’t work
for defining carbohydrates that have an impact on blood glucose
levels, as there seems to be no relation between saccharide chain
length and blood glucose response levels.

Most European countries define carbohydrates
differently than we do in North America. As already discussed, FDA
mandates that carbohydrate be calculated as the difference between
total grams of the food, and the sum of protein, fat, ash, and
moisture. Canada utilizes a similar methodology. By contrast,
European countries usually determine the available carbohydrate, by
doing a direct analysis to find the amount of mono-, di-, and
polysaccharides in a given food. The North American method results
in an overstatement of available carbohydrate content because it
includes non-carbohydrate compounds and non-available carbohydrates
or fiber. As an example, the carbohydrate and energy content of a
portion of spaghetti calculated directly is 50.6 grams of
carbohydrate and 237 calories, but calculation by difference (the
North American method) yields 64.6 grams of carbohydrate and 321
calories. This overstates available carbohydrates by almost 28%,
and overstates caloric content by over 35%. Thus, descriptions of
carbohydrate consumption in North America are probably overstating
the available carbohydrate content, due to the FDA requiring
carbohydrate calculation by difference.[92] Of course, determining available carbohydrate
content by direct analysis would cost more money and require all
new databases, so it seems unlikely that there will be large-scale
support amongst food manufacturers for a change in definitions.

VI. Conclusions and Proposals for Change

A. Conclusion

In an era when every single major diet book
advocates restricting some or most carbohydrates (even the Atkins
diet allows vegetables once desired weight is attained), the
response of the FDA, USDA and DHHS has been disappointing. Despite
mainstream acceptance of the wisdom of choosing foods with low a
low glycemic index, the Dietary Guidelines for Americans and Food
Guide Pyramid continue to advocate 6 to 11 servings of grains each
day, without distinguishing between healthy, low-glycemic index
carbohydrates and unhealthy high-glycemic index refined
carbohydrates. The FDA has not helped matters by clinging to an
outdated definition of carbohydrates that overstates the available
carbohydrate of any given food, nor by failing to provide an
adequate definition of complex carbohydrates to enable Americans to
pursue the benefits of increasing their intake of complex
carbohydrates. As time goes by, and more and more consumers hear of
successful weight loss on the Atkins diet, or the Zone or
SugarBusters diet, the advice of the government agencies in charge
of the public health will begin to seem antiquated and irrelevant.
If the agencies continue to ignore the differences amongst
carbohydrates, and continue to demonize fat without even
criticizing over-consumption of carbohydrates, the agencies may
lose legitimacy in the eyes of the public.

B. Proposals for Change

Going forward, the agencies can do a lot to improve
their image in the public eye and simultaneously improve the health
of the American public. First, the Food Guide Pyramid and Dietary
Guidelines for Americans must be updated to reflect the current
knowledge about refined carbohydrates such as white rice, potatoes,
and white bread. The Harvard School of Public Health has proposed a
new, healthier food pyramid that reflects the latest research on
optimal diet.[93] The new pyramid emphasizes whole grain foods and
plant oils, also recommending increased consumption of vegetables.
Alcohol is recommended in moderation, and a calcium supplement can
replace dairy foods on the pyramid. The very top of the pyramid is
split between red meat and butter, and highly refined carbohydrates
white rice, white bread, potatoes, pasta and sweets. No less of an
institution than Harvard has accepted the scientific evidence that
Americans are consuming too many refined carbohydrates. When will
the USDA catch on and revise its Food Guide Pyramid?

Second, the Secretary of the Department of Health
and Human Services should reconsider its decision to define
carbohydrates by difference, possibly adopting the European
approach to defining carbohydrates. Given what we know about blood
glucose levels and fat storage, lumping together those nutrients
that cause no rise in blood glucose levels (e.g., fiber), with
those that cause rapid increases in blood glucose levels, simply
makes no sense and only serves to annoy dieters and diabetics.
Admittedly, this would change the food labels of thousands of
foods, and cause companies to perform more testing of their
products to determine the new carbohydrate content. While this may
not be inexpensive, the benefits to diabetics and low-carbohydrate
dieters would be immense, and American carbohydrate consumption
would cease to be overstated. As to claims that this would confuse
the American public, if the Atkins web page can explain why fiber
doesn’t count as a carbohydrate, surely the USDA could do the
same.

Finally, the FDA can also help Americans to get
healthier. Although there are some general principles for
determining whether a food has a high glycemic index or a low one,
sometimes it is not easy to tell which is the healthy option.
Potatoes, long thought to be a great source of starchy complex
carbohydrates, are now on the list of bad, high-glycemic index
foods, while sweet potatoes have a low glycemic index. White rice
has a high glycemic index, while brown rice has a fairly low
glycemic index. Bananas have a high glycemic index, whereas most
legumes have a low one. It is difficult for consumers wishing to
monitor their blood glucose levels to remember the data for all of
the possible foods they may wish to eat.

FDA can assist these consumers by allowing
voluntary declaration of the glycemic load of a food. The glycemic
load is preferable to the glycemic index for these purposes because
the glycemic load takes into account the carbohydrate, protein and
fat content of a food. For example, carrots have a high glycemic
index, but a rather low glycemic load, because while the
saccharides digest rather quickly, the fiber in them slows down the
digestion process such that blood glucose levels don’t rise
very much. If the FDA would allow food manufacturers to include
glycemic load voluntarily, consumers could choose those foods that
have the least impact on blood glucose levels, thus helping them to
eat healthier and possibly lose weight. This would allow the
previously-called low-carbohydrate bars to differentiate themselves
from sugar-laden high-protein bars, and allow consumers to
comparison shop for bars based on glycemic load. The voluntary
declaration of glycemic load would also greatly assist diabetics in
choosing food choices that help them to treat diabetes through
diet, keeping their blood glucose levels stable by carefully
choosing foods with a low glycemic load.

Although the benefits of declaring the glycemic
load of foods would be even greater if all foods were required to
declare the glycemic load, this would require food manufacturers to
create a new database of the blood glucose responses to each food
they produce, which could prove costly. Nonetheless, the procedure
for measuring glycemic load is not very complex nor costly, and
books are available cheaply that give the glycemic index of common
foods. Also, many common foods have their glycemic index and
glycemic load in a database maintained by the University of
Sydney’s GI website, available at www.glycemicindex.com. The
database is searchable by food and/or glycemic index or glycemic
load. If databases containing hundreds of foods are already in
existence, it cannot cost that much to calculate the glycemic index
or glycemic load of a given food. Food manufacturers that produce
healthy, low-glycemic load foods would eagerly pay the costs of
testing to declare their healthy glycemic load on their label, and
other manufacturers may be shamed into trying to find ways to lower
the glycemic load of their foods, which would obviously improve the
overall health of Americans.

The inclusion (whether voluntary or mandatory) of
the glycemic load on food labels would obviate the need for a
definition of complex carbohydrates, since most of the benefits
reported for complex carbohydrates are actually those benefits for
all low-glycemic index foods. In theory, the government could
define complex carbohydrates as foods with a glycemic load less
than a certain cutoff, but if the glycemic load is on the food
label then this would be superfluous. For those food manufacturers
that choose not to put the glycemic load on their foods, consumers
may simply assume that the glycemic load is rather high, or may
choose foods that have the glycemic load listed. Therefore, the
market would create pressure on manufacturers to list the glycemic
load, and a definition for complex carbohydrates would be
unnecessary.

C. The Future

The health of the country is at stake. Americans
are getting fatter than ever, and yet the government seems to be
ignoring information that virtually every nutritionist and American
dieter “knows” to be true. If the government’s
recommendations aren’t changed soon, people may wonder why
they should listen to the government when it comes to nutrition at
all. Fortunately, it’s not too late. If the government adopts
the proposals outlined here, it would increase its perceived
legitimacy as guardian of the public’s nutrition, and would
be seen as finally responding to criticisms of the current system.
It’s time for the government to make some changes regarding
nutritional recommendations.

Appendix A: Current USDA Food Guide
Pyramid

Appendix B: Harvard School of Public
Health Recommended Food Pyramid[94]

[2] See generally “Statistics Related to Overweight
and Obesity,” National Institute of Diabetes and Digestive
and Kidney Diseases of the National Institutes of Health (available
at http://www.niddk.nih.gov/health/nutrit/pubs/statobes.htm#other)
(2003).

[6] See National Nutrition Montioring and Related
Research Act of 1990, 7 U.S.C. 5341 (2003).

[7] See Dietary Guidelines for Americans, 1980 to 2000,
Center for Nutrition Policy and Promotion, USDA, May 30, 2000
(available at http://www.usda.gov/cnpp/Pubs/DG2000/Dgover.PDF). The
2000 Dietary Guidelines for Americans now has 10 principles: 1) aim
for a healthy weight; 2) be physically active each day; 3) let the
Pyramid guide your food choices; 4) choose a variety of grains
daily, especially whole grains; 5) choose a variety of fruits and
vegetables daily; 6) keep food safe to eat; 7) choose a diet that
is low in saturated fat and cholesterol, and moderate in total fat;
8) choose beverages and foods to moderate your intake of sugar; 9)
choose and prepare foods with less salt; and 10) if you drink
alcoholic beverages, do so in moderation.

[22] See “It Really Has Been a Big Fat Lie,”
Dr. Robert Atkins, at
http://atkinscenter.com/Archive/2002/7/17-676178.html (stating
“Sunday, July 7, 2002, was one of the most gratifying days of
my life—and one that validated the controlled carbohydrate
nutritional approach to weight management and good
health.”).

[24] See generally The Columbia University College of
Physicians and Surgeons Complete Home Medical Guide, Chapter 5
“Essential Nutrients and Their Functions”, Tapley et
al. (available online at
http://cpmcnet.columbia.edu/texts/guide/hmg05_0002.html#5.2) (links
to this chapter are given on the Federal government’s Food
and Nutrition Information Center’s web site).

[25] For discussion of carbohydrates generally, see
“Carbohydrates in the Diet,” Janice Hermann, Oklahoma
Cooperative Extension Service, available at
http://pearl.agcomm.okstate.edu/fci/health/t-3117.html, also linked
to from the Food and Nutrition Information Center web site.

[26] Information on fats was taken from “A
Consumer’s Guide to Fats,” by Eleanor Mayfield, and
first appeared in the May 1994 FDA Consumer; it has since been
updated in January of 1999 and the updated version is available
online at
http://www.pueblo.gsa.gov/cic_text/food/fatguide/fatguide.html.

[38] See “How Much Fat Can I Eat,” Natural
Health, Section 3, Vol. 32, p. 64 (April 1, 2002) (expert panel of
four dietary experts, one of which advocating the low-fat Ornish
diet, and one advocating the low-carbohydrate Atkins diet, coming
to these points of agreement).

[43] See “Changes in plasma lipids and other
cardiovascular risk factors during 3 energy-restricted diets
differing in total fat and fatty acid composition,” Noakes
and Clifton, American Journal of Clinical Nutrition, 71(3):706-12,
2000.

[45] “Weight-loss with low or high carbohydrate
diet?” Golay et al, International Journal of Obesity &
Related Metabolic Disorders: Journal of the International
Association for the Study of Obesity. 20(12):1067-72, 1996 Dec.

[46] See “New Research on Atkins Diet Challenges
30 years of Nutritional Dogma,” Daniel Haney, Associated
Press, available at
http://atkinscenter.com/Archive/2003/3/12-103820.html.

[48] See “It’s Time to Build An Improved
Food Pyramid,” Atkins, available at
http://atkinscenter.com/Archive/2003/2/10-425583.html. For purposes
of this information, the usual convention of recording individuals
with a body mass index (BMI) between 25 and 29 as overweight, and
individuals with a BMI 30 or over as being obese.